The nurse is caring for a client who sustained a compound fracture of the right tibia/fibula postoperative ORIF (open reduction internal fixation). A complete assessment of the affected extremity would include:
Capillary refill, color of extremity.
Pedal pulses.
ACE wrap, Velcro boot, and hanging weights.
Pin sites.
Temperature, sensation, and movement of toes.
Correct Answer : A,B,D,E
Choice a reason:
Assessing capillary refill and the color of the extremity is essential for determining the vascular status of the limb. A normal capillary refill time is less than 2 seconds and indicates good blood flow. The color should be consistent with the rest of the body, without pallor or cyanosis, which could indicate compromised circulation.
Choice b reason:
Checking pedal pulses is another critical aspect of assessing vascular integrity. The presence of strong and equal pulses in both feet suggests that the blood supply to the lower extremities is not compromised.
Choice c reason:
While the ACE wrap and Velcro boot are part of the postoperative management to provide support and protection to the affected limb, and hanging weights might be used for traction, these are not part of the physiological assessment of the extremity.
Choice d reason:
Monitoring pin sites for signs of infection, such as redness, swelling, or discharge, is crucial in a client with ORIF. Infection can lead to complications that may affect the healing process and the integrity of the fixation.
Choice e reason:
Evaluating the temperature, sensation, and movement of toes helps in assessing for potential nerve damage or compartment syndrome. Any changes in these parameters should be reported immediately as they may signify serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Ulnar deviation, which is the angling of the fingers towards the little finger side of the hand, is more commonly associated with rheumatoid arthritis, not osteoarthritis. Osteoarthritis typically affects the joint's cartilage, leading to pain and stiffness, rather than causing the fingers to deviate.
Choice B reason:
Symmetric joint involvement is also more characteristic of rheumatoid arthritis. Osteoarthritis usually affects joints asymmetrically, meaning it's more likely to affect one side of the body or one particular joint at a time.
Choice C reason:
Weight loss is not a direct manifestation of osteoarthritis. In fact, being overweight is a risk factor for developing osteoarthritis due to the increased stress on weight-bearing joints. However, weight management through diet and exercise can be part of the treatment plan for osteoarthritis to alleviate symptoms and improve joint function.
Choice D reason:
Joint stiffness and limited range of motion are hallmark manifestations of osteoarthritis. These symptoms result from the breakdown of cartilage within the joints, which leads to pain and difficulty moving the affected joint. Stiffness is often most noticeable upon waking or after periods of inactivity, and the range of motion may decrease as the condition progresses.
Correct Answer is D
Explanation
Choice A Reason
A potassium level of 5.0 mEq/L is at the upper limit of the normal range, which is typically between 3.5 and 5.0 mEq/L. While this level should be monitored, especially in the context of diabetes where the patient may be at risk for hyperkalemia due to potential kidney issues, it is not immediately alarming¹.
Choice B Reason
A creatinine level of 4.4 mg/dL is significantly higher than the normal range of 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. This indicates severe renal impairment or kidney failure, which is a serious complication of diabetes mellitus. Immediate intervention is required to address this critical issue¹.
Choice C Reason
A hemoglobin level of 10.7 g/dL is slightly below the normal range for adults, which is generally 13.8 to 17.2 g/dL for males and 12.1 to 15.1 g/dL for females. This could indicate mild anemia, which can be a complication of diabetes but is not as immediately concerning as a high creatinine level¹.
Choice D Reason
A Blood Urea Nitrogen (BUN) level of 22 mg/dL is within the normal range, which is typically between 7 and 20 mg/dL. This level does not indicate immediate concern and is not as critical as the elevated creatinine level¹.
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